Labor AQ – Flashcard

question

How should a nurse direct care for a client in the transition phase of the first stage of labor? Decreasing intravenous fluid intake Helping the client maintain control Reducing the client’s discomfort with medications Having the client use simple breathing patterns during contractions
answer

Helping the client maintain control (Assisting the client in maintaining control is the most difficult part of labor. The client needs encouragement and support to cope. Intravenous fluids may need to be increased because of the increase in metabolism. Medication at this time will depress the newborn and is contraindicated. Breathing patterns at this time should be complex and require a high level of concentration to distract the client.)
question

A client is admitted to the emergency department in active labor. The client is bearing down, the fetal head is crowning, and birth appears imminent. Which breathing pattern should the nurse instruct the patient to adopt? Take slow, deep breaths Hold her breath and push with each contraction Breathe faster than usual with long cleansing breaths Pant and then exhale through the mouth with pursed lips
answer

Pant and then exhale through the mouth with pursed lips (The client cannot bear down when panting and exhaling. The objective is to control the birth and prevent injury to both mother and newborn. The nurse should place a hand on the perineum to apply gentle pressure and then support the head as it emerges. Slow breaths enhance relaxation; this type of breathing is impossible to achieve when the fetal head is crowning. Holding the breath and pushing will result in a precipitous birth that could cause injury to both mother and newborn. Breathing faster than usual and taking long cleansing breaths are impossible to achieve when the fetal head is crowning.)
question

What is the nurse’s priority assessment for a client in the fourth stage of labor? Degree of relaxation Distention of the bladder Extent of breast engorgement Presence of mother-infant bonding
answer

Distention of the bladder (A distended bladder impedes contraction of the uterus, predisposing the client to hemorrhage. Relaxation is a priority before birth; in the fourth stage the client is often euphoric. It is too soon to assess breast engorgement because it occurs on the third or fourth postpartum day. It is too soon to assess bonding; this progresses with care and responsibility.)
question

An expectant couple asks the nurse about the cause of low back pain during labor. The nurse replies that this pain occurs most often when the fetus is positioned how? Breech Transverse Occiput anterior Occiput posterior
answer

Occiput posterior (Persistent occiput posterior positioning causes intense back pain, the result of fetal compression of the sacral nerves. The breech position is not associated with back pain. The transverse position is not associated with back pain. Occiput anterior, the most common fetal position, generally does not cause back pain.)
question

During labor the nurse encourages the client to void periodically. The nurse knows that an overdistended urinary bladder during labor can do what? Predispose the client to uterine hemorrhage after birth Interfere with the assessment of cervical dilation Prevent the diagnosis of cephalopelvic disproportion Delay expulsion of the placenta after the birth of the neonate
answer

Predispose the client to uterine hemorrhage after birth (An overdistended urinary bladder prevents the uterus from contracting after birth; contraction of the uterus constricts blood vessels, preventing hemorrhage. A digital examination to assess vaginal dilation does not require an empty urinary bladder to be accurate. An overdistended urinary bladder may impede descent, but does not interfere with the diagnosis of cephalopelvic disproportion. Delaying expulsion of the placenta does not interfere with the third stage of labor.)
question

Which breathing technique should the nurse instruct the client to use as the head of the fetus is crowning? Shallow Blowing Slow chest Modified paced
answer

Blowing (Blowing forcefully through the mouth controls the strong urge to push and allows for a controlled birth of the head. A shallow breathing pattern does not help control expulsion of the fetus. Slow chest breathing is used during the latent phase of the first stage of labor; it is not helpful in overcoming the urge to push. Modified paced breathing is used during active labor when the cervix is dilated 3 to 7 cm; it is not helpful in overcoming the urge to push.)
question

A laboring client expresses concern about the effect that an intravenous analgesic may have on her fetus. What is the best response by the nurse to reassure the client? “I’ll dilute the medication so it won’t have an immediate impact on the baby.” “I’ll just give a half-dose of the medication while the uterus is in its relaxed phase.” “It will be administered during a contraction, when the uterine blood vessels are constricted.” “It will be administered in the proximal port of your IV so that you have immediate pain relief.”
answer

“It will be administered during a contraction, when the uterine blood vessels are constricted.” (Giving the medication during a contraction, when the uterine vessels are constricted, keeps the medication within the maternal vascular system for several seconds and decreases the impact on the fetus. The other options are incorrect because none of these responses involves administration during a contraction.)
question

The cervix of a client in labor is fully dilated and effaced. The head of the fetus is at +2 station. What should the nurse encourage the client to do during contractions? Relax by closing her eyes Push with her glottis open Blow to slow the birth process Pant to prevent cervical edema
answer

Push with her glottis open (The contractions in the second stage of labor are expulsive in nature; having the client push or bear down with the glottis open will hasten expulsion. Contractions are now intense and the client will be unable to relax; relaxation occurs between contractions. Having the client close her eyes, blow, or pant will prevent pushing and should not be encouraged until the fetal head crowns (+4 station) and a controlled birth is desired.)
question

A client in the active phase of the first stage of labor begins to tremble, becomes very tense during contractions, and is quite irritable. She frequently states, “I can’t take this a minute longer.” What does this behavior indicate to the nurse caring for her? There was no preparation for labor. She should receive an analgesic for pain. She is entering the transition phase of labor. Hypertonic uterine contractions are developing.
answer

She is entering the transition phase of labor. (The contractions become stronger, last longer, and occur erratically during the transition phase; the intervals between contractions become shorter than the contractions themselves; the client needs to apply a great deal of concentration and effort to pace her breathing with each contraction. Even clients who have been adequately prepared will experience these behaviors during the transition phase of the first stage of labor. Administration of an analgesic at this time may reduce the effectiveness of labor and depress the fetus. There is no indication that the contractions are hypertonic.)
question

A nurse assesses the frequency of a client’s contractions by timing them from the beginning of a contraction until when? The uterus starts to relax The end of a second contraction The uterus has relaxed completely The beginning of the next contraction
answer

The beginning of the next contraction (Timing until the beginning of the next contraction is the accepted way of determining the frequency of contractions. The time between beginning of a contraction and when the uterus starts to relax is not an indication of the duration of a contraction. The time from the beginning of a contraction to the end of a second one does not reflect the frequency of contractions. Complete relaxation of the uterus indicates the end of a contraction, but measuring the time from the beginning of the contraction until relaxation occurs is not the accepted way of timing the frequency of contractions.)
question

The nurse admits a client in active labor to the birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. What stage of labor has this client reached? First Latent Second Transitional
answer

First (The first stage of labor lasts from the onset of contractions until the cervix is fully dilated at 10 cm. The client is in the early phase of the first stage of labor. There is no latent stage of labor. The second stage of labor lasts from complete dilation to birth. There is no transitional stage of labor; transition is the last phase of the first stage of labor.)
question

When the cervix of a woman in labor is dilated 9 cm, she states that she has the urge to push. Which action should the nurse implement at this time? Having her pant-blow during contractions Placing her legs in stirrups to facilitate pushing Encouraging her to bear down with each contraction Reviewing the pushing techniques taught in childbirth classes
answer

Having her pant-blow during contractions (Although there are exceptions, the information given indicates that the best response is inhibiting pushing by having the client use pant-blow breathing. Pushing may cause cervical trauma when the cervix is not completely dilated. It is too early to prepare for the second stage of labor or to have the client bear down with each contraction if the cervix is not fully dilated. At this time the client is completely introverted and will be unreceptive to a review of pushing techniques.)
question

What is the priority nursing action during a client’s second stage of labor? Assessing the perineum for bulging Administering the prescribed analgesia Helping the client pant with each contraction Catheterizing the client before the head reaches +3 station
answer

Assessing the perineum for bulging (A bulging perineum is caused by the pressure of the fetal head against the perineal area and usually signifies imminent birth. Pain medication is not administered this close to the birth; it crosses the placental barrier and can cause respiratory distress in the newborn. During the second stage of labor the client is encouraged to push, not pant, with each contraction. Catheterization may be indicated earlier in labor so uterine contractions are not impeded; voiding will occur spontaneously as the client pushes.)
question

A nurse is assessing a primigravida who was admitted in early labor after her membranes have ruptured. She is at 41 weeks’ gestation. Her contractions are irregular, and her cervix is dilated 3 cm. The fetal head is at station 0, and the fetal heart rate tracing is reactive. How can the nurse help the client facilitate labor? Encourage her to watch television. Take a walk around the unit with her. Ask her to maintain a left-lateral position. Promote the patterned, paced breathing technique.
answer

Take a walk around the unit with her. (Walking may increase the frequency and intensity of the contractions. Although watching TV may be a relaxing activity, it will not help stimulate labor. At this time there is no indication that the client should assume the left-lateral position. During early labor, slow chest or abdominal breathing helps the client relax; the patterned, paced breathing technique is more appropriate for the transition phase of labor.)
question

While performing Leopold maneuvers on a client who has been admitted to the birthing room, the nurse identifies a firm, round prominence over the symphysis pubis; a smooth, convex structure along her right side; irregular lumps along her left side; and a soft roundness in the fundus. What is the fetal position? LOP RSA ROA LOA
answer

ROA (The fetus is in a right occiput anterior (ROA) position; the prominence over the symphysis suggests a vertex presentation, and the fetal occiput and back are in the right anterior quadrant. Left occiput posterior (LOP) is ruled out because the occiput is not located in the left posterior quadrant; the occiput and back are on the mother’s right side. Right sacral anterior (RSA) is ruled out because the fetus is in a vertex, not a breech, presentation. Left occipital anterior (LOA) is ruled out by the presence of irregular lumps on the left side, suggesting that the fetus’s back is in the mother’s right quadrant.)
question

While caring for a client in labor, the nurse notes that during a contraction there is a 15-beat-per-minute acceleration of the fetal heart rate above the baseline. What is the nurse’s most appropriate action at his time? Call the practitioner to prepare for an imminent birth. Turn the mother on her left side to increase venous return. Record the fetal response to contractions and continue to monitor the heart rate. Document the fetal heart rate abnormality and monitor the fetal heart rate continuously.
answer

Record the fetal response to contractions and continue to monitor the heart rate. (Periodic accelerations are the most reassuring of fetal heart rate indicators, regardless of the cause. This increase in the fetal heart rate does not require intervention by the practitioner at this time. Turning the mother on her left side to increase venous return is done when a fetal heart rate deceleration occurs. This is not a fetal heart rate abnormality and does not require a specific amount of time for observation; if the interventions are effective, monitoring should continue as before.)
question

While caring for a client during labor, what does the nurse remember about the second stage of labor? It ends at the time of birth. It ends as the placenta is expelled. It begins with the transition phase of labor. It begins with the onset of strong contractions.
answer

It ends at the time of birth. (The second stage of labor begins with full cervical dilation and ends with the birth of the infant. The third stage of labor begins after birth, continues until the separation of the placenta from the uterine wall, and ends with the expulsion of the placenta. The transition phase of labor is the last phase of the first stage of labor. The onset of strong contractions occurs during the active phase of the first stage of labor. )
question

The nurse observes a laboring client’s amniotic fluid and decides that it is the expected color and consistency. Which finding supports this conclusion? Clear, dark amber colored, and containing shreds of mucus Straw-colored, clear, and containing little white specks Milky, greenish yellow, and containing shreds of mucus Greenish yellow, cloudy, and containing little white specks
answer

Straw-colored, clear, and containing little white specks (By 36 weeks’ gestation, amniotic fluid should be pale yellow with small particles of vernix caseosa present. Dark amber-colored fluid suggests the presence of bilirubin, an ominous sign. Greenish-yellow fluid may indicate the presence of meconium and suggests fetal compromise. Cloudy fluid suggests the presence of purulent material.)
question

The fetus of a client in labor is found to be at +1 station. Where would the nurse locate the fetus’s head? On the perineum High in the pelvis Just below the ischial spines Slightly above the ischial spines
answer

Just below the ischial spines (The term station is used to indicate the location of the presenting part. The level of the tip of the ischial spines is considered zero station. The position of the bony prominence of the fetal head is described in centimeters, minus (above the spines) or plus (below the spines). On the perineum, referred to as crowning, is designated as +5. High in the pelvis is indicated by the term floating, which means that the presenting part has not yet engaged in the pelvis. A station of -1 indicates that the head is just above the ischial spines. )
question

What nursing action is the priority for a client in the second stage of labor? Check the fetus’s position. Administer medication for pain. Promote effective pushing by the client. Explain that breastfeeding can start right after birth.
answer

Promote effective pushing by the client. (Effective pushing will hasten the passage of the fetus’s presenting part through the birth canal. The fetal position is established before the second stage. Birth is imminent, and medication given at this time will depress the newborn’s respirations. Although the mother may breastfeed after the birth, during the second stage of labor she should be concentrating on the birth process, not feeding the infant.)
question

A woman at 40 weeks’ gestation is having contractions. Wondering whether she is in true labor, she asks, “How will you know if I’m really in labor?” Which information should the nurse provide to the patient at this time? The cervix dilates and becomes effaced in true labor. Bloody show is the first sign of true labor. The membranes rupture at the beginning of true labor. Fetal movements lessen and become weaker in true labor.
answer

The cervix dilates and becomes effaced in true labor. (The major difference between true and false labor is that true labor can be confirmed by the presence of dilation and effacement of the cervix. Bloody show may occur before or after true labor begins. The membranes may rupture before or after labor begins. Fetal movements continue unchanged throughout labor.)
question

The partner of a woman in labor is having difficulty timing the frequency of contractions and asks the nurse to review the procedure. How should contractions be timed? From the end of one contraction to the end of the next contraction From the end of one contraction to the beginning of the next contraction From the beginning of one contraction to the end of the next contraction From the beginning of one contraction to the beginning of the next contraction
answer

From the beginning of one contraction to the beginning of the next contraction (The frequency of contractions is timed from the beginning of one contraction to the beginning of the next; this is the definition of one contraction cycle. The beginning, not the end, of a contraction is the starting point for timing the frequency of contractions. The time between the end of one contraction and the beginning of the next contraction is the interval between contractions. Timing from the beginning of one contraction to the end of the next contraction is too long a timeframe and will produce inaccurate information.)
question

A client in active labor is admitted to the birthing room. A vaginal examination reveals that her cervix is dilated 6 to 7 cm. In light of this finding, what does the nurse expect? Client may experience nausea and vomiting. Client’s bloody show will become more profuse. Client will experience uncontrollable shaking of her legs. Client’s contractions will become longer and more frequent.
answer

Client’s contractions will become longer and more frequent. (This is an accurate description of contractions as labor progresses through the active portion of the first stage of labor. Nausea and vomiting occurs in the transition phase of the first stage of labor. More profuse bloody show and uncontrollable shaking of the legs occur in the transition phase of the first stage of labor.)
question

Nursing assessment of a client in labor reveals that she is entering the transition phase of the first stage of labor. Which clinical manifestations support this conclusion? Facial redness and an urge to push Bulging perineum, crowning, and caput Less intense, less frequent contractions Increased bloody show, irritability, and shaking
answer

Increased bloody show, irritability, and shaking (Increased bloody show, irritability, and shaking are some of the classic signs of the transition phase of the first stage of labor. The increase in bloody show is related to the complete dilation of the cervix, the irritability is related to the intensity of contractions, and the shaking is believed to be a vasomotor response. Facial redness and an urge to push are associated with the start of the second stage of labor. A bulging perineum, crowning, and caput signal that birth is imminent. Less intense, less frequent contractions may signal uterine hypotonicity, which may occur throughout the first stage of labor. )
question

What is the desired outcome for the intrapartum client during the third stage of labor? Absence of discomfort Firmly contracted uterine fundus Efficient fetal heart beat-to-beat variability Maternal respiratory rate within the expected range
answer

Firmly contracted uterine fundus (The third stage of labor spans the time from the birth of the baby to the delivery of the placenta; a firmly contracted uterus is desired because it minimizes blood loss. Providing comfort is a desirable goal, but is secondary to the life-threatening possibility of hemorrhage associated with a boggy uterus. Efficient fetal heart beat-to-beat variability is a concern in the first and second stages of labor; it is no longer applicable after the fetus is born. The maternal respiratory rate may vary above or below this range.)
question

A woman in labor with her third child is dilated to 7 cm, and the fetal head is at station +1. The client’s membranes rupture. What is the nurse’s priority intervention? Notify the practitioner. Observe the vaginal opening for a prolapsed cord. Reposition the client on a sterile towel on her left side. Check the fetal heart rate while observing the color of the amniotic fluid.
answer

Check the fetal heart rate while observing the color of the amniotic fluid. (Fetal well-being is the priority. The fetal heart rate will reflect the fetus’s response to the rupture of the membranes, and the color of the amniotic fluid will reveal whether there is meconium staining. Notifying the practitioner is necessary if the nurse’s assessments reveal fetal compromise. Although checking the vaginal opening for cord prolapse is important, it is not the priority; the fetal head is engaged at station +1. Although positioning the client on the left side promotes placental perfusion, it is not the priority, and a sterile pad is not needed.)
question

Upon arriving in the birthing room the nurse finds the client lying on her back with her head on a pillow and the bed in a flat position. The nurse explains that it is important to avoid lying in the supine position because of what reason? It may precipitate a severe headache. It can impede the progression of labor. It may cause nausea as labor progresses. It will prevent adequate blood flow to the fetus.
answer

It will prevent adequate blood flow to the fetus. (When the pregnant woman lies supine, pressure of the uterus against the vena cava reduces circulation; decreased perfusion of the placenta results in decreased blood flow to the fetus. The supine position should not precipitate a headache, although it can lead to supine hypotension. Although the supine position can prolong labor, it is not the primary reason for a position change. As labor progresses toward the transition phase, nausea may occur; this is unrelated to the client’s position.)
question

The nurse assists a client to the bathroom to void several times during the first stage of labor. Why is this is an important component of nursing? A full bladder is often injured during labor. A full bladder may inhibit the progress of labor. A full bladder jeopardizes the status of the fetus. A full bladder predisposes the client to urinary infection.
answer

A full bladder may inhibit the progress of labor. (A full bladder encroaches on the uterine space and impedes the descent of the fetal head. The bladder may become atonic, but is not physically damaged during the course of labor. A full bladder may lead to prolonged labor, but generally does not jeopardize fetal status as long as adequate placental perfusion continues. A full bladder during labor does not predispose the client to infection.)

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